KidStong Conference 2012
Jason Roush, DDS
WV State Dental Director
Gina Sharps, R.D.H, B.S., MPH Candidate
WVU School of Dentistry
Session Objectives:
• Understand normal oral health in the
school-aged child
• Recognize emergency and abnormal
pathologies presenting in the school
setting
• Examine the role of the school nurse and
school staff in the response and
recommendations of Dental Emergencies
Name that Smile!
Highlights from the US Surgeon
General’s Report
• The single most common chronic childhood
disease is dental cavities
• For the first time in 40 years, tooth decay is on
the rise in 2-5 yrs olds.
• Social/economic impact - 51 million school hours
are lost each year to dental-related illness.
Source: U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General
Highlights from the US Surgeon
General’s Report
• Oral health is integral to general health.
• Oral diseases and disorders affect health and
well-being throughout life.
• The most common dental diseases (dental
cavities and periodontal disease) are
PREVENTABLE.
Source: U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General
Tooth Decay
Periodontal Disease
Gum Disease
(Infection of the gums)
gingivitis and periodontitis
Oral Health = Overall Health
Oral infections related to:
 diabetes
 heart disease
 stroke
 bacterial endocarditis
 lung disease
 poor birth outcomes
Psycho-social impact:
 low self-esteem
 poor appearance
 job eligibility
For Want of a Dentist
Pr. George's Boy Dies After Bacteria
From Tooth
Spread to Brain
Source: Washington Post ,
February 28, 2007, Page B01, Mary Otto
Untreated Cavities Can Lead
to….
• Extreme Pain
• Spread of Infection
• Difficulty chewing, poor
nutrition, below average
weight
• Costly dental treatment
• More dental decay and
crooked bite in adult teeth
Consequences of Dental
Caries
• Missed school days
• Impaired speech development
• Inability to concentrate in
school
• Reduced self-esteem
• Possible systemic illness for
children with special health
care needs
Oral Health Disparities
80% of tooth decay
is found in 25% of
school-aged children
What about West Virginia?
Nationally
• 61 % of children aged 15 have
been affected by dental caries
• 1 of 5 Medicaid covered
children receive a single
dental visit each year
West Virginia
• 66 % of children aged 15
have been affected by
dental caries
• By graduation, the rate
jumps to 84%
Session Objectives:
• Understand the role of oral health in the
school-aged child
– Proper development of the primary and
permanent dentition
– Variants of dental disease and basic
pathology
Session Objectives:
• Recognize emergency and abnormal
pathologies presenting in the school
setting
Top 10
•
•
•
•
•
Abscess
Ulcer
Pericornitis
Ectopic eruption
Fracture tooth/ chip
• Avulsed/displaced
tooth
• Toothache- -decay
• Dry socket
• Soft/Hard Tissue
Injuries
Case Presentation #1
(toothache)
•
Meet Ethan- Ethan is a 5 year old Caucasian male and is sent to your office after
lunch b/c he complains to his teacher that something hurts in the back of his mouth.
His teacher is not overly concerned b/c Ethan has never complained of a toothache
before and she feels he might be trying to get out of math and reading scheduled for
the afternoon class time. Although, the teacher feels its unrelated, she has noticed
that Ethan demonstrates a consistent lack of ability to concentrate on all classroom
tasks. At first she tells Ethan his discomfort is probably just a piece of an apple that
they had for lunch stuck in his teeth and not to worry but go back to his desk and start
his math work. After 10 minutes, Ethan comes back up to her desk with tears in his
eyes saying his mouth still hurts. Reluctantly, the teacher sends Ethan to your office.
What now???
Protocol for Toothache
• DO or DONOT place aspirin on tooth or gum tissue?
• Check child’s temperature and observe for respiratory
distress
• Contact parent and arrange to take child to the dentist
immediately
• Follow-up 24 hours after first contact
• If the child is old enough– have them rinse vigorously
with warm salt water or try using dental floss to clean out
any debris.
Case Presentation #2
(toothache)
•
Meet Sylvester- Sylvester is a 4 year old,
Caucasian male participating in your
county round up health screenings.
Unfortunately, when you arrive at school
the day of the round up, the DH
scheduled to help is now out sick so now
you have to conduct the dental
screenings….You think “Just Great!!”
What Now??
Protocol for Toothache
• Check child’s temperature and observe for respiratory
distress (airway)
• Contact parent and arrange to take child to the dentist
immediately
• Follow-up 24 hours after first contact
• If the child is old enough– have them rinse vigorously
with warm salt water or try using dental floss to clean out
any debris.
Other TA Cases
And yet more TA Cases
And still more TA Cases
Case Presentation #3
• Meet Susie Q-Susie is being a bit
temperamental today over her
lunch. As soon as she sits down
to eat her tater tots and ketchup,
she busts out crying and refuses
to eat any more. Her teacher tries
to calm her and asks “Why all the
fuss?” then Susie points to
this…..
Oral Ulcers:
Classifications and Etiology
• Apthous ulcer
• Cold/canker sore
• Fever blisters
Canker sores
(etiology ?,
contagious?)
Cold sores (herpes,
contagious?)
• Traumatic lesion
•
•
•
•
•
German measles
Chickenpox
Mumps
Impetigo
Streptococcal
infection
• Clarks Solution-1/3 Maalox,
1/3 Benadryl, 1/3 Viscous
Xylocaine
Protocol for Assessing Ulcers
•
•
•
•
•
WEAR GLOVES
Record location, type, severity of lesions
Check child’s temperature
Advise child to avoid salty or spicy foods
Ice may be applied to provide temporary relief
• Contact parent if lesions spread or persist
• Child can rinse with warm salt water if old enough to
swish and expectorate.
• Administer acetaminophen if needed and possible.
Case Presentation #4
•
Meet Silas-Silas has just started first
grade and one day after school, his mom
catches you in the office and pulls down
Silas lower lip to show you this!! She asks
if this is normal? Why is this happening?
Will it fix itself? Do the teeth have to be
pulled? Are all his teeth going to come in
like this? Hes probably going to need
braces, right??? Questions, Questions,
Questions!!!!
•
Also, she admits she is concerned b/c she
is deathly afraid of the dentist and b/c of
her dental fear she has avoided taking
Silas to the dentist. Now what???
Case Presentation #5
• Meet Angelo (his friends
call him A). A is a 17
year old high school
student. He is physically
fit, doesn’t use tobacco,
and comes from an
affluent family in your
community. A stops by
your office complaining of
a lot of pain in the back of
his mouth. He opens wide
and shows you this. You
say, you have ________.
Protocol for Tx of Pericornitis
• Tx for minor symptoms of
pericoronitis (spontaneous pain,
localized swelling,
purulence/drainage, foul taste) is
irrigation.
• Tx for Major symptoms of
pericoronitis (difficulty swallowing,
enlarged lymph nodes, fever, limited
mouth opening, facial
cellulitis/infection) are usually treated
with antibiotics.
(16-23)
Protocol for Tx of Pericornitis
•
•
•
•
•
•
In most instances the S&S will recur if the tooth is not extraction>>>>>>> infection
can eventually spread to other areas of the mouth.
The most severe cases are treated in a hospital and may require intravenous
antibiotics and surgery.
The removal of the wisdom tooth should occur at a time when the acute phase or
"infection" is not present, as extracting this tooth during the time of the
acute/painful infection can cause the infection to spread to dangerous area around
the throat.
The dentist will usually clean the area and/or prescribe antibiotics and wait for it
to calm down until scheduling the extraction of it.
Pericoronitis can be managed with local debridement and warm salt water rinses.
It should go away in about one week. However, if the tooth does not completely
enter the mouth and food and bacteria keep building up under the gum,
pericoronitis will more than likely return.
Pericoronitis does not cause any long-term effects. If the affected tooth is removed
or erupts fully into the mouth, the condition cannot return.
Case Presentation #6
•
Meet Ali-Ali is a 13 year
Caucasian female. She is known
throughout school as being a
rowdy kid. One afternoon, Ali is
sent to your office and when she
tries to explain what's wrong, you
have trouble understanding her
speech. She opens her mouth
and points to her tongue. You
think, “Wow, that’s a pretty shade
of green”
Protocol for Tx Infections of the
Soft Tissue
• Remove Source of
Infection
• Drain Infection if
necessary
• Antiobiotic coverage
• Peridex rinse
Case Presentation #7
•
Meet Eric-Eric is a 17 year old
male and is your neighbors son.
You know that he had his wisdom
teeth extracted over spring break
and as far as you know, the
procedure was uncomplicated.
The 3rd molars were extracted on
Friday and today, Monday, finds
Eric in your office in a
considerable amount of pain. Eric
asks you “Why is this happening?”
•
Possible Etiology?
Protocol for tx of Dry Socket
• Advise the parent to consult the attending
dentist
• Administer an aspirin substitute for pain, if
permitted
Protocol for Prolonged Bleeding After A
Tooth Extraction
• Fold a sterile 2"x2" gauze and place on the
extraction site. Have the child bite continuously
for 30 minutes, without disturbing it.
• If the bleeding is bright red (not just oozing), you
may place a damp tea bag wrapped in sterile
gauze and have the child bite continuously for
30 minutes, without disturbing it.
• If bleeding cannot be controlled within an hour,
or is excessive, advise the parent to consult the
attending dentist.
Fun with Fractures,
Displacements, and Avulsion
Case Presentation #7
• Meet Mark-It was the last
Friday afternoon of the
school year when Mark an
8 year old boy got into a
nest of yellow jackets on the
play ground. While fleeing
from the bees, Mark ran
into a fixed metal flag pole,
suffering a fractured front
tooth.
Protocol for Fractured Tooth
• If the tooth is broken, chipped, or fractured, see your dentist as soon as
possible. Otherwise your tooth could be damaged further or become infected,
possibly causing loss of tooth.
• In the meantime, try the following self-care measures:
– If the tooth is painful, take acetaminophen or another over-the-counter pain reliever
– If the break has caused a sharp or jagged edge, cover it with a piece of wax, paraffin, or
chewing gum
– If you must eat, eat soft foods and avoid biting down on the broken tooth
• Treatment for a broken or chipped tooth will depend on how severely it is
damaged. If only a small piece of enamel broke off, the repair can usually be
done simply in one office visit. A badly damaged or broken tooth may require
a more lengthy and costly procedure.
Displacement
• Luxation
• Intrusion
• Extrusion
• Luxated=Loose or
Dislocated
Protocol for Luxated/Fractured Teeth
• Luxated-DO NOT
attempt to move the
tooth into correct
position
• Gently cleanse with
warm water
• Contact parent and
arrange to take to
dentist immediately
• Dentist will reposition,
splint and evaluate for
RCT
Protocol for Avulsion
• Primary (baby) teeth
are not reimplanted.
Permanent teeth are
reimplanted.
• DO NOT use
antiseptic on the
tooth. Do not handle
the tooth
unnecessarily.
Protocol for Avulsion
• Contact parent.
• Contact dentist.
• Take child and tooth
to the DDS ASAP!
Avulsed tooth
• Handle by the crown of
the tooth (NOT the root!)
• Rinse gently, if needed.
(NEVER scrub)
• Replant into socket, hold
in place
• Transport tooth (if unable
to replant) in milk, saline
solution, or saliva. Water
as a last resort.
• DO NOT LET DRY OUT!
Time is critical!
Reimplantation must occur w/in 2 hours
• The tooth may also be
held in the cheek area
if the child is old
enough not to swallow
it.
• It can be wrapped in
plastic or even a wet
towel.
• Commercial emergency
tooth preserving
systems are available
for purchase.
Reimplanting
• Inspect the tooth for
fractures before
reimplanting it.
• Place the tooth back in
the socket before a blood
clot forms if possible.
• After gently reimplanting
the tooth, have the child
hold it in place with a
tissue or clean cloth.
Protocol for Soft Tissue Injuries
• Try to calm the injured person
• If bleeding profusely: Contact parent and
arrange for emergency services
• If minor bleeding: Apply pressure (approx.
ten minutes)
• If bleeding continues past ten minutes,
contact parent and arrange for EMTs or
transport to emergency room.
Protocol for Soft Tissue Injuries
• Gently clean area
• Apply cold compress
to minimize swelling,
10 minutes on and 5
minutes off the injury
site.
• Assess for referral to
dentist or emergency
room
Oral-Facial Trauma
• Serious head injury should be ruled out.
• Evaluate for S&S of concussion including:
 Nausea/vomiting
 Dilated pupils
 Dizziness
 Cold/clammy
 Headache
 Memory Loss
Oral-Facial Trauma
• Check for tooth fragments or knocked out teeth
in the mouth, lip and cheek areas.
• If swelling or bruising is present, apply cold
compress alternating 10 minutes on and 5
minutes off the site of the injury.
• Try to calm the injured person.
• Determine the type of injury
• If bleeding profusely:
contact parent and arrange for emergency
services
• If minor bleeding, apply pressure (approx.
ten to fifteen minutes)
• If bleeding continues past ten to fifteen
minutes, contact parent and arrange for
EMTs or transport to emergency room.
Protocol for Broken or Dislocated Jaw
• Contact parent and EMTs to take child to
emergency room immediately
• Note time of injury and any other injuries present
• Check for clear airway
• Keep head elevated
• Apply cold compress
• Monitor vital signs and consciousness
• Record all observations
Orthodontic Mishaps: Protocol
• Take out the loose or
broken appliance/wire if it
can be easily removed. If
unable to remove easily,
contact parent to arrange
take the child to the
orthodontist.
• Protruding wires may be
covered by orthodontic
wax, sugarless gum,
gauze, or cotton ball
Orthodontic Mishaps: Protocol
• A tongue blade or
pencil eraser may also
gently bend the wire.
• Loose bands,
appliances, or wires do
not require emergency
attention if it is not
bothering the child, but
the parent should be
notified to contact the
orthodontist.
Dental First Aid Supply Kit
• Gloves (should be
worn during any oral
exam)
• Mask (if blood splatter
possible)
• Eyewear (if blood
splatter possible)
• Sterile gauze 2" x 2"s
•
•
•
•
•
•
•
•
Flashlight
Tongue Blade
Ice Pack
Saline Solution
Orthodontic Wax
Tea Bags
Dental Floss
Toothbrush
Thank-You!
gsharps@hsc.wvu.edu
Jason.m.roush@wv.gov
Questions??